Improving Healthy Eating for Adolescents in India

Programmes to Prevent NCDs in India: Improving Healthy Eating for Adolescents | May 2018

Evidence Brief | May 2018 Programmes to Prevent Noncommunicable Diseases (NCDs) in India: Improving Healthy Eating for Adolescents Veronica Thomas, Katie Moran, Ishu Kataria, Pamela Williams, Linda Squiers

India is facing a substantial rise in noncommunicable diseases (NCDs), many of which are caused by poor dietary habits early in life. This brief presents effective strategies to improve healthy eating among adolescents in India. NCDs are diseases that are not caused by infection and are not transmitted through contact with a person. Nearly 2 out of 3 of all deaths in India are now due to NCDs. This is a significant increase over the past 30 years.1 Also, the leading causes of death in India have shifted. In 1990, for example, diseases Nearly caused by diarrhoea and respiratory infections led to the most deaths. These are communicable diseases and spread from one person to another in a variety of ways. In 2016, two NCDs, heart disease and chronic obstructive pulmonary disease (COPD)—a 2 out of 3 disease that causes blocked airflow in the lungs—were the leading causes of death.2 This shift from deaths caused by communicable diseases to deaths caused by NCDs of all deaths in has occurred in low- and middle-income countries, like India, where often there is little India are now support for preventing and treating NCDs.3 due to NCDs.1 NCDs affect people of all ages, and many risky behaviours, like smoking and unhealthy eating, are started or reinforced in adolescence. Impaired nutrition even during infancy increases the risk of NCDs later in life.4 Poor dietary habits, for example, are a big cause of NCDs such as diabetes and heart disease. This is a complex issue in India, because the country faces both the widespread lack of proper nutrition and obesity. With more than 14 million children who are obese, India is second only to China for the greatest number of obese children in the world.5 Effective science-based programmes are needed to combat risk factors, such as unhealthy diets, and ultimately improve poor health and reduce deaths related to NCDs. To help identify these programmes, we evaluated the most recent science and identified effective programmes to improve eating habits among adolescents in India.

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Our Methods and Findings

What We searched the scientific literature for peer-reviewed studies that met the studies did 69 following criteria: studies we review?

Dates Databases Languages Population Keywords January 2007– • PubMed • English Adolescents Adolescent/adolescence/ September 2017 • Embase • Hindi aged 13 to young adult/teenage AND • Web of Science 24 in India India AND • CAB Abstracts • IndMED Intervention/program AND • Directory of Open Prevention AND Access Journals Obesity/overweight/ • Google Scholar diabetes/heart disease • New York OR Academy of diet/dietary habits/food Medicine Grey intake/food consumption/ Literature nutrition/eating/sodium/ Database fat/fruit/vegetable We graded the studies based on: 32 - the strength of the study design; studies - if the study reasonably could be repeated using the same methods, different participants, and different researchers; - whether the programme could be easily implemented in other contexts; and - the impact of the programme on eating behaviours to help prevent NCDs. We identified cross-cutting themes in the programme components and 9 found that: studies - 9 studies had strong designs and showed results that improved adolescents’ eating habits. This brief presents findings and insights from these 9 studies.

What type of • All 9 studies used school-based health education programmes for middle school health education and/or high school students. programmes did these • These programmes were carried out in both public and private schools. • The states where these studies took place include Tamil Nadu, Delhi, Karnataka, studies use? Haryana, and Chandigarh.

Who participated in Average number of participants Age range of participants these studies? 580 13–18 (median: 302) years old

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What programme • Each programme had an educational component carried out in the classroom. components did • Other components included engaging families, changing school policy (such as the types of foods allowed at meetings or events), changing the food environment (such these studies use? as foods offered at the canteen), and engaging teachers. • Programmes took place over 9 months on average (with a range from 3 to 30 months).

What study designs • 8 experimental/quasi-experimental studies: One group and methods did of participants received the programme being studied while another group did not. In the four experimental Experiment/Quasi-experiment these studies use? studies, students or schools who received the intervention were randomly assigned. In the four quasi- experimental studies, the assignment of the intervention was not random. Cohort

• 1 cohort study: In a cohort design, a particular group = Intervention of people took part in the same programme and were observed over a specific time period.

What did these These studies looked at changes in participants’ beliefs, eating patterns, and body studies look at? composition: 7 7 4 studies* studies studies

assessed knowledge, assessed changes in assessed changes in weight, body attitudes, and/or intentions eating patterns and mass index (BMI), and other body to change eating behaviours food intake changes (such as lowering cholesterol) *These numbers do not total 9, as some studies looked at more than one component.

What did these Of the 9 studies reviewed: studies find? 7 6 2 studies studies studies

found positive changes found positive changes found reductions in weight and BMI, in knowledge, attitudes, in eating patterns and or improvements in other physical and/or intentions food intake measures

Just 2 of the 9 programmes changed people’s weight, BMI, or other physical measures. This is most likely because the length of the programmes was short (on average, 9 months), and most only followed up with participants immediately after the programme. Using body changes as an outcome measure is challenging, as adolescents are still growing, and an upward shift in these measures is expected in this age group. How We Can Apply the Study Findings Because studies are not often designed to show which factors made the most difference, it can be difficult to figure out what made a programme effective. As such, we looked across the set of studies that showed positive changes for adolescents in India and tried to pull out the factors that most of these programmes had in common.

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Recommendations Tip! These programme Here are some important things to think about when developing healthy eating components are not programmes for adolescents in India. To get the most benefit out of your programme, mutually exclusive. it’s good to combine multiple components. Rather, they should be used in conjunction and 1. Use a programme design based on theory coordination with each other One good approach is social cognitive theory.6 This theory says that learning happens for maximum benefit. As within a social context that can influence a person’s behaviours. This context includes demonstrated by the most external and internal factors, such as a person’s neighbourhood, their education, effective programmes, a and past experiences. Using a solid theory will help you evaluate how and why the multicomponent approach is programme works. more promising for longer- 2. Conduct educational sessions with groups of adolescents term improvements in Offer group educational sessions to all adolescents in a community or school, rather knowledge, attitudes, and than trying to reach individual adolescents at high risk and providing one-on-one behaviours. counselling. Taking an approach that reaches a whole group may help make positive changes to the social norms and social support around healthy eating. In other words, if an adolescent’s friends are all learning the same information about nutrition, they are more likely to reinforce that knowledge amongst themselves. 3. Prepare schools and staff to deliver the programme Educate school staff on why eating healthy foods is important for adolescents, given the rise in NCDs in India. Encourage school staff to take ownership by providing them with tools and resources to help them carry out the programme on their own. For example, “Since both undernutrition provide educational posters about healthy foods that they can hang up in the canteen. and overnutrition is associated with NCD 4. Use multiple teaching techniques to engage adolescents burden, multicomponent, Adolescents’ brains change and develop rapidly, and they are often distracted by evidence-based, nutrition other interests, such as friends, sports, or social media. To pique their interest and keep improvement programmes them engaged in education and counselling about good nutrition, use multimedia and interventions are the materials and activities, including films, flash cards, quizzes, computer-assisted tools, and need of the hour. These competitions. interventions need to be 5. Make it easier for adolescents to choose healthy foods implemented through Provide more nutritious food choices­—such as fruits, vegetables, and dairy—in school a well-coordinated, canteens, homes, and neighbourhood shops. Change policies and the day-to-day multisectoral action plan at environment to support behaviour changes. For instance, schools might choose not the country level in various to sell unhealthy food in the school canteen. To overcome the cost barrier for some health promotion settings to fruits and vegetables, try to get financial support from the government or nonprofit prevent NCDs.” organisations for local produce. --Dr. Monika Arora 6. Engage parents in nutrition education and behaviour change Executive Director, Health Parents can be important teachers and role models about good nutrition and Related Information champions for eating a healthy diet. Involve parents early on with a school kickoff or Dissemination Amongst parent-teaching event to describe your planned programme approach, educate them Youth (HRIDAY) and about the importance of preventing NCDs early in life, and encourage them to offer Governing Board Member, more fruits and vegetables at home and in their children’s packed lunches. Consider Healthy India Alliance sending educational materials, family assignments, or even healthy snacks home with students. The information on each study is presented in Table 1.

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Table 1. Characteristics of Effective School-Based Programmes to Address Adolescents’ Eating Habits in India

PROGRAMME Anand, Bakshi, Kalpana, Rani, Saraf, Singhal, Thakur, Tiwari, Ulavannavar, 20157 20128 20109 201210 201511 201012 201613 201114 201515 COMPONENTSa Theoretical Foundation

Group Nutrition Education

Engagement of Teachers and Administrators Multimedia Strategies

Changes to the Food Environment Family Involvement

OUTCOMESb Nutrition Knowledge

Attitudes and Intentions towards Nutrition Fruit and Vegetable Intake

Unhealthy Food Intake

Biochemical Changes

Body Mass Indicators (BMI/ Weight)

Table Legend Intervention Statistically significant No change Not measured Change included change aProgramme Components

Theoretical Foundation: Use a theory, such as social cognitive theory, to guide programme design. Group Nutrition Education: Provide lessons about diet and nutrition to an entire group of adolescent peers. Engagement of Teachers and Administrators: Get buy-in from and include school staff in carrying out the programme. Multimedia Strategies: Use innovative multimedia approaches (such as videos) and educational lectures. Changes to the Food Environment: Change the food that is available in school, such as removing deep-fried foods from the canteen. Family Involvement: Educate parents about healthy eating behaviours and provide resources to support healthy eating at home. bParticipant Outcomes

Nutrition Knowledge: Improve adolescents’ understanding of good nutrition and diet, such as which foods are considered healthy. Attitudes and Intentions towards Nutrition: Improve adolescents’ positive perception of healthy eating and motivation to improve their eating habits. Fruit and Vegetable Intake: Get adolescents to eat more fruits and vegetables during the programme period. Unhealthy Food Intake: Get adolescents to eat fewer unhealthy foods, such as fried foods or chips, during the programme period. Biochemical Changes: Improve adolescents’ biochemical levels, such as lowering cholesterol levels. Body Mass Indicators: Improve adolescents’ physical body metrics, including weight, BMI, and circumference of body parts such as arms and waist.

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Efforts by the Government of India Midday Meal (MDM) Scheme The Ministry of Human Resources Development, Government of India, is implementing a national programme called the Midday Meal Scheme in schools, with the goal of improving the nutritional status of children and increasing school attendance. This programme can be better utilized and planned to support the NCD agenda, as it can help form healthy food habits.16 Food Safety and Security Authority of India guidelines and programme The Food Safety and Security Authority of India (FSSAI) has issued guidelines on HFSS foods (foods high in fat, sugar, and salt). These guidelines focus on specific nutrients, including fats and sugars, through more transparent and accessible nutritional labelling, taxation, and children’s advertisement regulation.17 The FSSAI also has undertaken initiatives to ensure delivery of safe, nutritious, and healthy food for all citizens through its Safe and Nutritious Food (SNF) campaign. This programme is a nationwide campaign to help school children adopt the habit of eating safe and eating right at home, school, work, and dining venues.18

“Youth can have a major Learnings from Other Countries influence on their own food To broaden the scope of school-based programmes or expand programmes into environment by demanding other settings, here are some guidelines and recommendations on healthy eating healthy and appealing food programmes for adolescents based on leading agencies in the United States and in their schools and homes, Europe. These additional programme components might work well outside of the and they can use their social classroom, but they will need to be adapted to the Indian context. media skills to spread good Use peer educators and leaders habits about healthy eating Adolescents often look to their peers for guidance and reinforcement. Use peer amongst each other. They educators or leaders to help their friends choose fruits and vegetables when they are can cause a healthy food out, instead of choosing deep-fried foods. To sustain impact beyond the programme revolution.” period, recruit and train peer leaders (both overweight and normal weight) to provide 19 --Dr. Rachel Nugent face-to-face support in making healthy food choices. In worksite programmes, engage Vice President managers and other company leaders to participate in challenges or competitions to help reinforce healthy behaviours.20 Global Noncommunicable Diseases Take nutrition education outside of the classroom RTI International Help students apply theoretical concepts and curricula in more experiential ways, like growing a garden or reading and analysing nutrition labels. Also, expand nutrition education beyond health courses. For example, science teachers might add a lesson about macronutrients—carbohydrates, protein, and fat, which provide the bulk of energy for humans. Or teachers can add field trips to local farms for hands-on learning about food, nutrition, and healthy eating.21 Develop a programme outside of the school entirely by educating older adolescents and promoting healthier choices at worksites.22

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Conduct early screening for obesity and poor diets in adolescents More than The United States Preventive Services Task Force (USPSTF) recommends obesity screenings for children and adolescents ages 6 years or older.23 However, more research 19% needs to be done on nutritional screening for habits and biochemical markers, such as cholesterol level.24 Once health risks or conditions are identified, the World Health of children in India Organization (WHO) recommends that health care providers offer diet counselling and are overweight or referral as part of routine primary care.25 These components might be included through 26 India’s National Adolescent Health Strategy, known as the Rashtriya Kishor Swasthya obese. Karyakram (RKSK) programme, and its Adolescent-Friendly Health Clinic component. Improve the environment where adolescents eat and play As shown in the India-based programmes described in this brief, replacing unhealthy foods in the canteen with healthy foods can be an effective programme. However, sustaining this is challenging given the high cost of some fruits and vegetables as compared with packaged foods. As recommended by WHO and USPSTF, schools or businesses might utilize public food distribution to underwrite locally grown produce. The government might also provide incentives and awards to urban designers and organisations that make health a priority in how they build communities and school campuses, as part of their Smart Cities project.27, 28 Increase access to clean water Increasing access to clean water in schools might support better nutrition and reduce 45% rates of obesity and overweight in adolescents and NCDs later in life. This may be partly of youth ages due to students replacing high-calorie, sugar-sweetened beverages, such as soda and juice, with water. The USPSTF recommends providing water fountains throughout 14 to 16 do not schools, putting steps in place to ensure that water fountains are kept up, and allowing eat any fruit on a students to have water bottles in classes.30 The US Centers for Disease Control and Prevention recommends making free water available to students during meal times.21 daily basis.29 Harness the power of technology More than 225 million Indians use the internet to search for information, enjoy online entertainment, and participate in social networking.31, 32 Internet-based and other technology-based coaching or self-management programmes might help adolescents reduce weight and maintain weight loss.19, 33 Amplify messages by using social marketing and media campaigns Use a mass media campaign on healthy diets, including social marketing strategies to reduce eating “bad” foods (such as sugar and salt) and promote eating “good” foods (such as fruits and vegetables).34, 35 For instance, eliminate barriers to behaviour change in schools and workplaces by placing healthier foods where they are easy to select (such as at eye level), setting up attractive displays of produce, and offering taste tests of new menu items.21, 35 Utilize laws and policies for widespread impact The national government, states, or specific schools might put in place school meal policies or requirements that ensure school breakfasts or lunches meet specific nutritional requirements, like India’s Mid-Day Meal programme. Consider policies that require foods and beverages sold during the school day—such as in vending machines, food carts, and canteens—and those served during school celebrations and events to meet established nutritional guidelines.35 Alternatively, schools could offer other items as rewards for healthy eating, such as extra time at recess or a note of recognition.21 These same policies could be used in worksites to improve diet and behaviours amongst adolescents in the workforce, such as offering healthy foods at company meetings.36 – 7 – Programmes to Prevent NCDs in India: Improving Healthy Eating for Adolescents | May 2018

Push for private-sector change and support “Making our diets healthier Food labelling in India currently is not strongly regulated. The domestic and regional is achievable, but to food industry might adopt their own set of best practices to show their social reverse the historical responsibility. To promote dietary education and informed choices, one approach trend of increased obesity might be to limit portion and package size to reduce calorie intake and the risk of and ill-health among overweight and obesity. Another approach might be to improve nutrition labelling of adolescents we need to see both packaged and prepared unpackaged foods to highlight calories, sugar, salt, and fat a variety of interventions. content.34 These will range from community or school-based Conclusion programmes to government policy and regulation. Only In this review, no single programme was shown to be the most effective approach through a multicomponent to dietary change in Indian adolescents. However, we identified 6 programme characteristics that appear to be effective in increasing knowledge, positive attitudes, approach can we and healthy eating habits, and in improving physical body indicators, such as BMI, waist expect to see significant measurement, and cholesterol level. improvements in eating habits among adolescents Overall, the best approach is to focus on creating an environment that supports positive knowledge, attitude, and behaviour change around healthy eating. This often leads to in India.” short-term and longer-term improvements in health and reduces NCD risk factors. --Liam Sollis In general, strong evaluations and plans to sustain the programmes were missing from PLAN International, UK the programmes we evaluated. These are two key components to lasting success. Both activities should be included when designing and investing in your programme.

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– 10 – RTI International’s NCD Initiative Programmes to Prevent RTI International’s Global Noncommunicable Disease Initiative is working with global partners and country leaders to design, implement, and evaluate interventions and Noncommunicable long-term solutions to address NCDs. Together, we are helping country-level partners to: Diseases (NCDs) • reduce premature mortality from NCDs; in India: • support the achievement of universal health coverage; Improving • strengthen health systems and responses to reduce harmful use of alcohol and Healthy Eating tobacco; and for Adolescents • improve access to essential medicines and treatments. May 2018 With 60 years of expertise in research, policy analysis and development, health economics and financing, on-the-ground project implementation, and strengthening health systems, RTI is an integral partner in both assessing and successfully addressing the economic and social impact of NCDs.

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Acknowledgements

Designed by: Mikayla Eason Special thanks to: Jeff Novey, Monika Arora, Toshiko Kaneda, Jonathan Klein, Rachel Nugent, and Liam Sollis

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